Fill in the following information to construct an Individualized Education Plan:
(See the Example for a partial illustration on how to use this form and see Subchapter 2 of the Assistance for Education of All Children with Disabilities for more legal information.)

Date of Meeting:

Presenting Problem



Objectives
(Who, What, When, How)

Objective 1:



Objective 2:



Objective 3:



Members of the IEP Team:

By my signature below, I affirm that I participated in the development of the above plan of action. (If you agree with the plan, please check the "Yes" space; if you disagree, please check the "No" space.)

Student: ______________________   Yes [   ]   No [   ]

Parent :_______________________   Yes [   ]   No [   ]

Parent: _______________________   Yes [   ]   No [   ]

Teacher: ______________________  Yes [   ]   No [   ]

Teacher: ______________________  Yes [   ]   No [   ]

Teacher: ______________________  Yes [   ]   No [   ]

Teacher: ______________________  Yes [   ]   No [   ]

Administrator: __________________  Yes [   ]   No [   ]

Counselor: ____________________   Yes [   ]   No [   ]

Spec. Ed.: ____________________   Yes [   ]   No [   ]

Other: ________________________   Yes [   ]   No [   ]